Provider Demographics
NPI:1124194840
Name:SISAM, DAVID A (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:SISAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 BELANGER ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360
Mailing Address - Country:US
Mailing Address - Phone:985-876-5451
Mailing Address - Fax:985-876-2025
Practice Address - Street 1:855 BELANGER ST
Practice Address - Street 2:SUITE 100
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360
Practice Address - Country:US
Practice Address - Phone:985-876-5451
Practice Address - Fax:985-876-2025
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06691R207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1349054Medicaid
A83164Medicare UPIN
5M630Medicare ID - Type Unspecified